Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries

Medicare Advantage Enrollment Following the 21st Century Cures Act in Adults With End-Stage Renal Disease

Importance

In January 2021, under the 21st Century Cures Act, Medicare beneficiaries with end-stage renal disease (ESRD) were permitted to enroll in private Medicare Advantage (MA) plans for the first time. In the first year of the Cures Act, there was a 51% increase in MA enrollment among beneficiaries with ESRD.

Objective

To examine changes in MA enrollment among Medicare beneficiaries with ESRD in the first 2 years of the Cures Act and, among beneficiaries newly enrolled in MA in 2021, to assess the proportion of beneficiaries who switched MA contracts and how the characteristics of contracts changed.

Design, Setting, and Participants

This cross-sectional, population-based time-trend study was conducted from January 2020 to December 2022. Eligible participants included Medicare beneficiaries with ESRD. Data analysis was conducted from August 2023 to March 2024.

Exposure

Enrollment in Medicare during the first 2 years of the 21st Century Cures Act.

Main Outcomes and Measures

The primary outcomes were enrollment in MA, switching between traditional Medicare (TM) and MA, and switching between MA contracts from 2021 to 2022.

Results

There were 718 252 unique Medicare beneficiaries with ESRD between 2020 and 2022 (1 659 652 beneficiary-years). In 2022, there were 583 203 beneficiaries with ESRD (mean [SD] age, 64.9 [14.1] years, 245 153 female (42.0%); 197 988 Black [34.0%]; 47 912 Hispanic [8.2%]). The proportion of beneficiaries with ESRD who were enrolled in MA increased from 25.1% (118 601 of 472 234 beneficiaries) in January 2020 to 43.1% (211 896 of 491 611 beneficiaries) in December 2022. Increases in MA enrollment were larger in the first year of the Cures Act (12.6 percentage points [pp]; 95% CI 12.3-12.8 pp) compared with the second year (5.7 pp; 95% CI, 5.5-5.9 pp). Changes between December 2020 and December 2022 ranged between 49.3% for Asian or Pacific Islander beneficiaries (difference = 13.0 pp; 95% CI, 12.2-13.8 pp) and 207.2% for American Indian or Alaska Native beneficiaries (difference = 17.0 pp; 95% CI, 15.3-18.7 pp). Changes were high among partial dual-eligible (difference = 35.5 pp; 95% CI, 34.9-36.1 pp; 134.7% increase) and fully dual-eligible beneficiaries (difference = 22.8 pp, 95% CI, 22.5-23.1 pp; 98.0% increase). Among 53 366 beneficiaries enrolled in MA in 2021, 37 439 (70.2%) remained in their contract, 11 730 (22.0%) switched contracts, and 4197 (7.9%) switched to TM in 2022. Compared with the characteristics of MA enrollees with ESRD in 2021, those in 2022 were more likely to be in contracts with lower premiums and with a rating of 4.5 stars or higher.

Conclusions and Relevance

In this cross-sectional time-trend study of Medicare beneficiaries with ESRD, MA enrollment continued to increase in the second year of the Cures Act, particularly among racially or ethnically minoritized individuals and dual eligible populations. These findings suggest need to monitor the equity of care for beneficiaries with ESRD as they enroll in managed care plans.

Medicare Advantage Plan Star Ratings and County Social Vulnerability

Importance

The star rating of a Medicare Advantage (MA) plan is meant to represent plan performance, and it determines the size of quality bonuses. Consumer access to MA plans with a high star rating may vary by the extent of social vulnerability in geographic regions.

Objective

To examine the association between a county's Social Vulnerability Index (SVI) and the star rating of a county's MA plans.

Design, Setting, and Participants

This cross-sectional study used 2023 Centers for Medicare & Medicaid Services data for all MA plans linked to 2020 county-level SVI data from the Centers for Disease Control and Prevention. Data were analyzed from March to October 2023.

Exposure

Quintile rank of county based on composite and theme-specific SVI scores, with quartile 1 (Q1) representing the least vulnerable counties and Q5, the most vulnerable counties. The SVI is a multidimensional measure of a county's social vulnerability across 4 themes: socioeconomic status, household characteristics (such as disability, age, and language), racial and ethnic minority status, and housing type and transportation.

Main Outcomes and Measures

County-level mean star rating and the number of MA plans with low-rated (<3.5 stars), high-rated (3.5 or 4.0 stars), and highest-rated (≥4.5 stars) plans.

Results

Across 3075 counties, the median county-level star rating was 4.1 (IQR, 3.9-4.3) in Q1 counties and 3.8 (IQR, 3.6-4.0) in Q5 counties (P < .001). The mean star rating of MA plans was lower (difference, -0.24 points; 95% CI, -0.28 to -0.21 points; P < .001), the number of low-rated plans was higher (incidence rate ratio, 1.81; 95% CI, 1.61-2.06; P < .001), and the number of highest-rated plans was lower (incidence rate ratio, 0.75; 95% CI, 0.70-0.81; P < .001) in Q5 counties compared with Q1 counties. Similar patterns were found across theme-specific SVI score quintiles and for 2022 star ratings.

Conclusions and Relevance

In this cross-sectional study, the most socially vulnerable counties were found to have the fewest highest-rated plans for MA beneficiaries. As MA enrollment grows in socially vulnerable regions, this may exacerbate regional differences in health outcomes for Medicare beneficiaries.

Medicare Advantage Under Fire: Public Criticism and Implications

Congressional hearings and public reports have drawn attention to problems afflicting Medicare Advantage (MA), the privatized version of Medicare. Private plans became a staple of Medicare through the passage of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Congress passed this law during a furor of privatization, when think tanks and powerful financial interests emphasized the power of corporations' profit incentive to improve the efficiency and quality of social enterprise. Yet the surging criticism of MA suggests a misalignment between the financial interest of some MA plans and the well-being of their patient populations. The criticisms range from deceptive marketing, ghost networks, and patient cherry-picking to unethical prior authorization denials and defrauding the government. In total, MA plans cost the federal government 22% more per patient than if these patients in question were enrolled in traditional Medicare. Moreover, it is not clear that this additional funding is producing proportional benefits. These developments raise questions about the presence of a profit incentive in Medicare, and perhaps health care more broadly.

New Supplemental Benefits and Plan Ratings Among Medicare Advantage Enrollees

Importance

In 2018, the US Congress gave Medicare Advantage (MA) historic flexibility to address members' social needs with a set of Special Supplemental Benefits for the Chronically Ill (SSBCIs). In response, the Centers for Medicare & Medicaid Services expanded the definition of primarily health-related benefits (PHRBs) to include nonmedical services in 2019. Uptake has been modest; MA plans cited a lack of evidence as a limiting factor.

Objective

To evaluate the association between adopting the expanded supplemental benefits designed to address MA enrollees' nonmedical and social needs and enrollees' plan ratings.

Design, Setting, and Participants

This cohort study compared the plan ratings of MA enrollees in plans that adopted an expanded PHRB, SSBCI, or both using difference-in-differences estimators with MA Consumer Assessment of Health Care Providers and Systems survey data from March to June 2017, 2018, 2019, and 2021 linked to Medicare administrative claims and publicly available benefits and enrollment data. Data analysis was performed between April 2023 and March 2024.

Exposure

Enrollees in MA plans that adopted a PHRB and/or SSBCI in 2021.

Main Outcomes and Measures

Enrollee plan rating on a 0- to 10-point scale, with 0 indicating the worst health plan possible and 10 indicating the best health plan possible.

Results

The study sample included 388 356 responses representing 467 MA contracts and 2558 plans in 2021. Within the weighted population of responders, the mean (SD) age was 74.6 (8.7) years, 57.2% were female, 8.9% were fully Medicare-Medicaid dual eligible, 74.6% had at least 1 chronic medical condition, 13.7% had not graduated high school, 9.7% were helped by a proxy, 45.1% reported fair or poor physical health, and 15.6% were entitled to Medicare due to disability. Adopting both a new PHRB and SSBCI benefit in 2021 was associated with an increase of 0.22 out of 10 points (95% CI, 0.4-4.0 points) in mean enrollee plan ratings. There was no association between adoption of only a PHRB (adjusted difference, -0.12 points; 95% CI, -0.26 to 0.02 points) or SSBCI (adjusted difference, 0.09 points; 95% CI, -0.03 to 0.21 points) and plan rating.

Conclusions and Relevance

Medicare Advantage plans that adopted both benefits saw modest increases in mean enrollee plan ratings. This evidence suggests that more investments in supplemental benefits were associated with improved plan experiences, which could contribute to improved plan quality ratings.

Medicare Advantage enrollment and outcomes of post-acute nursing home care among patients with dementia

Enrollment in Medicare Advantage (MA) has been rapidly growing. We examined whether MA enrollment affects the outcomes of post-acute nursing home care among patients with Alzheimer's disease and related dementias (ADRD). We exploited year-to-year changes in MA penetration rates within counties from 2012 through 2019. After adjusting for patient-level characteristics and county fixed effects, we found that MA enrollment was not associated with days spent at home, nursing home days, likelihood of becoming a long-stay resident, hospital days, hospital readmission, or 1-year mortality. There was a modest increase in successful discharge to the community by 0.73 percentage points (relative increase of 2.4%) associated with a 10-percentage-point increase in MA enrollment. The results are consistent among racial/ethnic subgroups and dual-eligible patients. These findings suggest an imperative need to monitor and improve quality of managed care among enrollees with ADRD.

Impact of overdose on health plan disenrollment among patients prescribed long-term opioids: Retrospective cohort study

CONTEXT

Health plan disenrollment may disrupt chronic or preventive care for patients prescribed long-term opioid therapy (LTOT).

PURPOSE

To assess whether overdose events in patients prescribed LTOT are associated with subsequent health plan disenrollment.

DESIGN

Retrospective cohort study.

SETTING AND DATASET

Data from the Optum Labs Data Warehouse which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages and geographical regions across the United States.

PATIENTS

Adults prescribed stable opioid therapy (≥10 morphine milligram equivalents/day) for a 6-month baseline period prior to an index opioid prescription from January 1, 2018 to December 31, 2018.

MAIN MEASURES

Health plan disenrollment during follow-up.

RESULTS

The cohort comprised 404,151 patients who were followed up after 800,250 baseline periods of stable opioid dosing. During a mean follow-up of 9.1 months, unadjusted disenrollment rates among primary commercial beneficiaries and Medicare Advantage enrollees were 37.2 and 13.9 per 100 person-years, respectively. Incident overdoses were associated with subsequent health plan disenrollment with a statistically significantly stronger association among primary commercial insurance beneficiaries [adjusted incidence rate ratio (aIRR) 1.48 (95% CI: 1.33-1.64)] as compared to Medicare Advantage enrollees [aIRR 1.15 (95% CI: 1.07-1.23)].

CONCLUSIONS

Among patients prescribed long-term opioids, overdose events were strongly associated with subsequent health plan disenrollment, especially among primary commercial insurance beneficiaries. These findings raise concerns about the social consequences of overdose, including potential health insurance loss, which may limit patient access to care at a time of heightened vulnerability.

Partner Plan Choices and Medicare Advantage Enrollment Decisions Among Older Adults

This study examines the association of partner Medicare Advantage plan status over 1 year with beneficiary and plan characteristics.

Legislative and Regulatory Options for Improving Medicare Advantage

The Medicare Advantage program was created to expand beneficiary choice and to reduce spending through capitated payment to private insurers. However, many stakeholders now argue that Medicare Advantage is failing to deliver on its promise to reduce spending. Three problematic design features in Medicare Advantage payment policy have received particular scrutiny: (1) how baseline payments to insurers are determined, (2) how variation in patient risk affects insurer payment, and (3) how payments to insurers are adjusted for quality performance. The authors analyze the statute underlying these three design features and explore legislative and regulatory strategies for improving Medicare Advantage. They conclude that regulatory approaches for improving risk adjustment and for recouping overpayments from risk-score gaming have the highest potential impact and are the most feasible improvement measures to implement.

Trends in healthy days at home for Medicare beneficiaries using the emergency department

BACKGROUND

Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status.

METHODS

We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status.

RESULTS

We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD.

CONCLUSIONS

Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.

Medicare Switching: Patterns Of Enrollment Growth In Medicare Advantage, 2006-22

Medicare Advantage (MA) has grown rapidly over the course of the past two decades and is projected to continue to grow. We examined sources of new enrollment in MA and analyzed the switching patterns between MA and traditional fee-for-service Medicare, using more recent and more detailed data than in previous analyses. We found that switching from fee-for-service Medicare to MA more than tripled between 2006 and 2022, whereas switching from MA to fee-for-service Medicare decreased, with the change rates accelerating since 2019. The share of switchers among all new MA enrollees rose from 61 percent in 2011 to 80 percent in 2022. Black, dual-eligible, and disabled beneficiaries had higher odds of switching in both directions, whereas younger and healthier beneficiaries had higher odds of switching from fee-for-service Medicare to MA but lower odds of switching from MA to fee-for-service Medicare. Two-thirds of annual switching between MA and fee-for-service Medicare in 2022 occurred in January, likely reflecting the open enrollment period.

Medicare Advantage Enrollment and Disenrollment Among Persons With Alzheimer Disease and Related Dementias

Importance

Large enrollment growth has been observed in the Medicare Advantage program, but less is known about enrollment patterns among persons with Alzheimer disease and related dementias (ADRD).

Objective

To evaluate patterns in Medicare Advantage enrollment and disenrollment among beneficiaries with or without ADRD.

Design, Setting, and Participants

This cross-sectional study used 6 national data sources between January 1, 2011, and December 31, 2018. Analyses were performed between June 2021 and August 2022. The cohort comprised US Medicare beneficiaries with acute or postacute care utilization between 2013 and 2018.

Exposure

ADRD diagnosis from an acute or postacute care encounter Medicare data source.

Main Outcomes and Measures

Enrollment in Medicare Advantage, disenrollment from Medicare Advantage to traditional Medicare, and contract exit (leaving a Medicare Advantage contract for traditional Medicare or a different Medicare Advantage contract).

Results

The 32 796 872 Medicare beneficiaries in the cohort had a mean (SD) age of 74.0 (12.5) years and included 18 228 513 females (55.6%). Enrollment in Medicare Advantage among beneficiaries with ADRD increased from 24.7% (95% CI, 24.7%-24.8%) in 2013 to 33.0% (95% CI, 32.9%-33.1%) in 2018, an absolute increase of 8.3 percentage points and a 33.4% relative increase after adjusting for demographic characteristics, comorbid conditions, and utilization and including county fixed effects. Among beneficiaries without ADRD, enrollment in Medicare Advantage increased by 8.2 percentage points from 27.6% (95% CI, 27.6%-27.6%) in 2013 to 35.8% (95% CI, 35.8%-35.8%) in 2018, a 29.7% relative increase over the study period. Beneficiaries with ADRD were 1.4 times as likely to disenroll from their Medicare Advantage contract to traditional Medicare (4.4% vs 3.2% in 2017-2018; P < .001) in adjusted analyses. Regardless of ADRD status, beneficiaries had similar rates of switching to a new Medicare Advantage contract. Differences in contract exit rates were associated with higher rates of disenrollment from Medicare Advantage to traditional Medicare among beneficiaries with ADRD vs those without ADRD (16.3% [95% CI, 16.2%-16.3%] vs 15.1% [95% CI, 15.1%-15.1%]). Beneficiaries with ADRD and dual eligibility for Medicaid enrollment had higher rates of contract exit than those without dual eligibility (19.7% [95% CI, 19.6%-19.7%] vs 14.9% [95% CI, 14.8%-14.9%]), and these differences were even greater than those among beneficiaries without ADRD and with and without dual-eligibility status, respectively (18.3% [95% CI, 18.2%-18.3%] vs 13.8% [95% CI, 13.7%-13.8%]).

Conclusions and Relevance

In this cross-sectional study of the Medicare population with acute and postacute care use, beneficiaries with ADRD had increasing enrollment in the Medicare Advantage program, proportional to the growth in overall enrollment, but their disenrollment from Medicare Advantage in the following year remained higher compared with beneficiaries without ADRD. The findings highlight the need to understand the factors associated with higher disenrollment rates and determine whether such rates reflect access or quality challenges for beneficiaries with ADRD.

Favorable Selection In Medicare Advantage Is Linked To Inflated Benchmarks And Billions In Overpayments To Plans

Increases in Medicare Advantage (MA) enrollment, coupled with concerns about overpayment to plans, have prompted calls for change. Benchmark setting in MA, which determines plan payment, has received relatively little attention as an avenue for reform. In this study we used national data from the period 2010-20 to examine the relationships among unobserved favorable selection, benchmark setting, and payments to plans in MA. We found that unobserved favorable selection in MA led to underpayment to counties with lower MA penetration and overpayment to counties with higher MA penetration. Because the distribution of MA beneficiaries has shifted over time toward counties that were overpaid, we estimate that plans were overpaid by an average of $9.3 billion per year between 2017 and 2020. Changes to risk adjustment in benchmark setting could likely mitigate the impact of favorable selection in MA.

Association of Medicare Program Type with Health Care Access, Utilization, and Affordability among Cancer Survivors

BACKGROUND

The Medicare Advantage program provides care to nearly half of Medicare beneficiaries, including a rapidly growing population of cancer survivors. Despite its increased adoption, it is still unknown whether or not the program improves healthcare access, outcomes, and affordability for cancer survivors.

METHODS

We performed a cross-sectional study of Medicare beneficiaries aged ≥ 65 years with a self-reported history of cancer from the 2019 National Health Interview Survey. We used multivariable logistic regression to evaluate the association between Medicare program type (Medicare Advantage vs. traditional Medicare) and measures of healthcare access, acute care utilization, and affordability.

RESULTS

We identified 4451 beneficiaries with a history of cancer, corresponding to 26.6 million weighted cancer survivors in 2019. Of the beneficiaries, 35.8% were enrolled in Medicare Advantage, whereas 64.2% were enrolled in traditional Medicare. The age, sex, racial and ethnic composition, household income, primary site of cancer, and comorbidity burden of Medicare Advantage and traditional Medicare beneficiaries were similar. In the adjusted analysis, there were no differences in healthcare access or acute care utilization between traditional Medicare and Medicare Advantage beneficiaries. However, cancer survivors enrolled in Medicare Advantage were more likely to worry about (34.3% vs. 29.4%; aOR, 1.3 (95% CI, 1.1-1.5)) or have problems paying (13.6% vs. 11.1%; aOR, 1.4 (95% CI, 1.1-1.8)) medical bills.

CONCLUSIONS

We found no evidence that Medicare Advantage beneficiaries with cancer had better healthcare access, affordability, or acute care utilization than traditional Medicare beneficiaries did. Furthermore, Medicare Advantage beneficiaries were more likely to report financial strain and have difficulty paying for their medical bills than were those with traditional Medicare. Despite the generous benefits and attractive incentives, Medicare Advantage plans may not be more cost-effective than traditional Medicare is for cancer survivors. Our study informs ongoing congressional deliberations to re-evaluate the role of Medicare Advantage in promoting equity among beneficiaries with cancer.

Trends in Cumulative Disenrollment in the Medicare Advantage Program, 2011-2020

Importance

The Medicare Advantage (MA) program is rapidly growing. While previous work has found that beneficiaries with substantial health needs disenroll from plans at higher rates, the long-term frequency of disenrollment is not well understood.

Objective

To compare cumulative disenrollment trends in the MA program by beneficiary and plan characteristics.

Design, Setting, and Participants

This retrospective, serial cross-sectional study included beneficiaries with any MA enrollment from January 1, 2011, to December 31, 2020. Data analysis took place from September 2022 to March 2023.

Exposures

Beneficiary characteristics, including race and ethnicity, length of Medicare enrollment, dual eligibility, and comorbidity burden, and contract characteristics, including vertical integration status, premium, and MA star rating.

Main Outcomes and Measures

The main outcome was disenrollment from an MA contract within 5 years. Rates of cumulative disenrollment by beneficiary and contract characteristics were compared. Pearson correlation coefficients were calculated to assess the correlation between a contract's 1-year disenrollment and the contract's disenrollment over a longer period.

Results

The sample included 82 377 917 beneficiaries (524 442 225 beneficiary-year observations; 56.7% female; mean [SD] age, 71.9 [10.3] years). After 1 year, 13.2% of nondually enrolled and 15.9% of dually enrolled beneficiaries had left their contract, increasing to 48.3% and 53.4%, respectively, after 5 years. Black enrollees disenrolled at the highest rates among race and ethnicity categories, with 14.8% disenrolling after 1 year and 52.6% disenrolling after 5 years. Contracts had a median disenrollment rate of 9.8% (IQR, 4.5%-19.0%) after 1 year and 56.1% (IQR, 23.1%-79.0%) after 5 years. Contracts rated 5 stars had substantially lower 5-year disenrollment rates (23.0% after 5 years compared with 41.2% for 4- to 4.5-star contracts and 67.2% for 3- to 3.5-star contracts). Disenrollment from a contract after 1 year was not well correlated with disenrollment after 5 years (r, 0.46).

Conclusions and Relevance

This cross-sectional study found substantial cumulative rates of disenrollment from MA plans within 5 years between 2011 and 2020, with wide variation in 5-year disenrollment by contract. The findings suggest that evaluating long-term disenrollment rates in MA performance measures may capture different outcomes than single-year disenrollment alone.

Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia

BACKGROUND

Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare's dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown.

OBJECTIVE

The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status.

RESEARCH DESIGN

Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns.

SUBJECTS

A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015-2019 Medicare Current Beneficiary Survey.

MEASURES

We assessed differences in ACO enrollment rates for patients with versus without dementia, and in dementia-relevant ambulatory care visit rates and validated care fragmentation indices among patients with dementia by ACO enrollment status.

RESULTS

Patients with versus without dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001), and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05).

CONCLUSION

Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits.

Medicare Advantage Disenrollment Patterns Among Beneficiaries With Multiple Chronic Conditions

This study examines whether Medicare Advantage (MA) enrollees with more chronic conditions were more likely to disenroll when MA enrollment grew rapidly from 2009 to 2019.

Impact of star ratings on Medicare health plan enrollment: A systematic literature review

BACKGROUND

The Medicare star ratings program was developed by the Centers for Medicare and Medicaid Services in 2007 as an approach to evaluate health plan performance and quality.

OBJECTIVE

This study aimed to identify and narratively describe studies that attempted to quantitatively assess the impact that Medicare star ratings have on health plan enrollment.

METHODS

A systematic literature review (SLR) was conducted of PubMed MEDLINE, Embase, and Google to identify articles that quantitatively assessed the impact of Medicare star ratings on health plan enrollment. Inclusion criteria consisted of studies that conducted quantitative analyses to estimate the potential impact. Exclusion criteria consisted of qualitative studies and studies that did not directly assess plan enrollment.

RESULTS

This SLR identified 10 studies that sought to measure the impact of Medicare star ratings on plan enrollment. Nine of the studies found that plan enrollment increased in accordance with increases in star ratings or that plan disenrollment increased with decreases in star ratings. One study conducted of data before the implementation of the Medicare quality bonus payment found contradictory results from one year to the next, whereas all the studies that assessed data after implementation found increases in enrollment in accordance to increases in star ratings or increases in disenrollment for decreases in star ratings. One concerning finding from some of the articles included in the SLR is that increases in star ratings had less of an impact on enrollment in higher-rated plans for ethnic and racial minorities and older adults.

CONCLUSIONS

Increases in Medicare star ratings led to statistically significant increases in health plan enrollment and decreases in health plan disenrollment. Future studies are needed to assess whether this increase has a causal association or is caused by additional factors outside of or in addition to increases in overall star rating.

Racial and ethnic disparities in access to and enrollment in high-quality Medicare Advantage plans

OBJECTIVE

Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower-quality plans, measured by a 5-star quality rating system. We examine whether differential access to high-rated plans was associated with this differential enrollment in high-rated plans by race and ethnicity among MA enrollees.

DATA SOURCES

The Medicare Master Beneficiary Summary File and MA Landscape File for 2016.

STUDY DESIGN

We first examined county-level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual-level characteristics only, and (2) individual-level characteristics and county-level MA plan offerings.

DATA COLLECTION/EXTRACTION METHODS

Not applicable PRINCIPAL FINDINGS: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high-rated plans (4-star plans or higher) and/or more number of low-rated plans (3.5-star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4-4.5 star plans than White enrollees, this difference substantially decreased after accounting for county-level MA plan offerings (-9.1 to -0.5 percentage points for Black enrollees, -15.9 to -5.0 percentage points for Asian/Pacific Islander enrollees, and -12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5-star plan. After accounting for county-level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5-star plans than White enrollees.

CONCLUSIONS

Differences in enrollment in high-rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions.

Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings

BACKGROUND

Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown.

OBJECTIVE

To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures.

DESIGN

Cross-sectional.

SETTING

Population-based.

PARTICIPANTS

Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program.

MEASUREMENTS

Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated.

RESULTS

Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings.

LIMITATION

Hospital performance measurement and risk adjustment differed slightly from those used by Medicare.

CONCLUSION

Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance.

PRIMARY FUNDING SOURCE

Laura and John Arnold Foundation.

Medicare Advantage Enrollment Among Beneficiaries With End-Stage Renal Disease in the First Year of the 21st Century Cures Act

Importance

Before 2021, most Medicare beneficiaries with end-stage renal disease (ESRD) were unable to enroll in private Medicare Advantage (MA) plans. The 21st Century Cures Act permitted these beneficiaries to enroll in MA plans effective January 2021.

Objective

To examine changes in MA enrollment among Medicare beneficiaries with ESRD after enactment of the 21st Century Cures Act overall and by race or ethnicity and dual-eligible status.

Design, Setting, and Participants

This cross-sectional time-trend study used data from Medicare beneficiaries with ESRD (both kidney transplant recipients and those undergoing dialysis) between January 2019 and December 2021. Data were analyzed between June and October 2022.

Exposures

21st Century Cures Act.

Main Outcomes and Measures

Primary outcomes were the proportion of Medicare beneficiaries with prevalent ESRD who switched from traditional Medicare to MA between 2020 and 2021 and those with incident ESRD who newly enrolled in MA in 2021. Individuals who stayed in traditional Medicare were enrolled in 2020 and 2021 and those who switched to MA were enrolled in traditional Medicare in 2020 and MA in 2021.

Results

Among 575 797 beneficiaries with ESRD in 2020 or 2021 (mean [SD] age, 64.7 [14.2] years, 42.2% female, 34.0% Black, and 7.7% Hispanic or Latino), the proportion of beneficiaries enrolled in MA increased from 24.8% (December 2020) to 37.4% (December 2021), a relative change of 50.8%. The largest relative increases in MA enrollment were among Black (72.8% relative increase), Hispanic (44.8%), and dual-eligible beneficiaries with ESRD (73.6%). Among 359 617 beneficiaries with TM and prevalent ESRD in 2020, 17.6% switched to MA in 2021. Compared with individuals who stayed in traditional Medicare, those who switched to MA had modestly more chronic conditions (6.3 vs 6.1; difference, 0.12 conditions [95% CI, 0.10-0.16]) and similar nondrug spending in 2020 (difference, $509 [95% CI, -$58 to $1075]) but were more likely to be Black (difference, 19.5 percentage points [95% CI, 19.1-19.9]) and have dual Medicare-Medicaid eligibility (difference, 20.8 percentage points [95% CI, 20.4-21.2]). Among beneficiaries who were newly eligible for Medicare ESRD benefits in 2021, 35.2% enrolled in MA.

Conclusions and Relevance

Results suggest that increases in MA enrollment among Medicare beneficiaries with ESRD were substantial the first year after the 21st Century Cures Act, particularly among Black, Hispanic, and dual-eligible individuals. Policy makers and MA plans may need to assess network adequacy, disenrollment, and equity of care for beneficiaries who enrolled in MA.

Beneficiary Switching Between Traditional Medicare and Medicare Advantage Between 2016 and 2020

This cohort study examines switching behavior in enrollment in Medicare Advantage and traditional Medicare.

Variations in Medicare Advantage Switching Rates Among African American and Hispanic Medicare Beneficiaries With Alzheimer's Disease and Related Dementias, by Sex and Dual Eligibility

OBJECTIVES

The objective of this study was to identify rates of switching to Medicare Advantage (MA) among fee-for-service (FFS) Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD) by race/ethnicity and whether these rates vary by sex and dual-eligibility status for Medicare and Medicaid.

METHODS

Data came from the Medicare Master Beneficiary Summary File from 2017 to 2018. The outcome of interest for this study was switching from FFS to MA during any month in 2018. The primary independent variable was race/ethnicity including non-Hispanic White, non-Hispanic African American, and Hispanic beneficiaries. Two interaction terms among race/ethnicity and dual eligibility, and race/ethnicity and sex were included. The model adjusted for age, year of ADRD diagnosis, the number of chronic/disabling conditions, total health care costs, and ZIP code fixed effects.

RESULTS

The study included 2,284,175 FFS Medicare beneficiaries with an ADRD diagnosis in 2017. Among dual-eligible beneficiaries, adjusted rates of switching were higher among African American (1.91 percentage points [p.p.], 95% confidence interval [CI]: 1.68-2.15) and Hispanic beneficiaries (1.36 p.p., 95% CI: 1.07-1.64) compared to non-Hispanic White beneficiaries. Among males, adjusted rates were higher among African American (3.28 p.p., 95% CI: 2.97-3.59) and Hispanic beneficiaries (2.14 p.p., 95% CI: 1.86-2.41) compared to non-Hispanic White beneficiaries.

DISCUSSION

Among persons with ADRD, African American and Hispanic beneficiaries are more likely than White beneficiaries to switch from FFS to MA. This finding underscores the need to monitor the quality and equity of access and care for these populations.

Turnover among new Medicare Advantage enrollees may be greater than perceived

OBJECTIVES

To characterize the proportion of Medicare Advantage (MA) enrollees who switched insurers or disenrolled to traditional Medicare (TM) in the years immediately after first choosing to join an MA health plan.

STUDY DESIGN

Retrospective analysis using 2012-2017 Medicare enrollment data.

METHODS

We studied enrollees who joined MA between 2012 and 2016 and identified all enrollees who changed insurers (switched insurance or disenrolled to TM) at least once between the start of enrollment and the end of the study period. We categorized each change as switching insurers or disenrollment to TM, and by whether the previous insurer had exited the market.

RESULTS

Among 6,520,169 new MA enrollees, 15.6% had changed insurance within 1 year after enrollment in MA and 49.2% had changed insurance by 5 years. More enrollees switched insurers rather than disenrolled, and most enrollees who changed insurers did not do so as a result of insurer exits.

CONCLUSIONS

New MA enrollees change insurers at a substantial rate when followed across multiple years. These changes may disincentivize insurers from investing in preventive care and chronic disease management and, as shown in several non-MA populations, may lead to discontinuities in care, increased expenditures, and inferior health outcomes.

Effects of Medicare advantage on patterns of end-of-life care among Medicare decedents

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on patterns of end-of-life care.

DATA SOURCES

We used data from the Master Beneficiary Summary File, the Medicare Provider Analysis and Review, hospice claims, the Minimum Data Set, the Outcome and Assessment Information Set, the Area Health Resources File, and Geographic Variation Public Use File for 2012-2014.

STUDY DESIGN

To address selective enrollment into MA, we exploited a discontinuity in payment rates by county population (urban floor payments) as an instrument.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries continuously enrolled in MA or TM during their last year of life between 2012 and 2014 using Medicare administrative data.

PRINCIPAL FINDINGS

We did not find evidence that MA enrollment led to a change in hospital admissions in the last 30 days of life, but MA enrollment decreased hospital as the site of death by 11.0 (95% CI: -13.9 to -8.1) percentage points. Once hospitalized, however, MA enrollment increased use of intensive care by 6.7 (95% CI: 0.3 to 13.1) percentage points and non-invasive mechanical ventilation by 9.2 (95% CI: 5.5 to 12.9) percentage points. MA enrollment increased hospice use by 6.2 (95% CI: 2.3 to 10.1) percentage points at time of death and 7.7 (95% CI: 3.8 to 11.6) percentage points in the last 30 days of life. Particularly, MA enrollment increased hospice admissions among those who were admitted to the hospital within 30 days prior to hospice admission by 18.8 (95% CI: 13.8 to 23.8) percentage points. However, MA enrollment decreased hospice admissions among those who were admitted to home health within 30 days prior to hospice admission by 18.6 (95% CI: -21.9 to -15.2) percentage points.

CONCLUSIONS

MA plans may improve end-of-life care by reducing hospital death while also improving access to hospice, especially among recently hospitalized persons.

Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program

IMPORTANCE

The 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk.

OBJECTIVE

To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022.

EXPOSURES

Enrollment in MA or attribution to an accountable care organization in the MSSP program.

MAIN OUTCOMES AND MEASURES

Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending.

RESULTS

The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific subcohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454; 95% CI, $1431-$3574), CHF ($3699; 95% CI, $1235-$6523), CKD ($2478; 95% CI, $1172-$3920), and hypertension ($2258; 95% CI, $1616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts.

CONCLUSIONS AND RELEVANCE

In this study, utilization and spending were consistently higher for MSSP than MA beneficiaries within the same health system even after adjusting for granular metrics of clinical risk. Nonclinical factors likely contribute to the large differences in MA vs MSSP spending, which may create challenges for health systems participating in MSSP relative to their participation in MA.

Completeness of cohort-linked U.S. Medicare data: An example from the Agricultural Health Study (1999–2016)

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We describe linked U.S. Medicare claims data in the Agricultural Health Study.

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Incomplete claims data were related to geographic, demographic, and health.

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We saw potential informative missingness by pesticide use and mortality.

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Incomplete data in Medicare-linked cohorts may impact sample size and validity.

Medicare Fee for Service (FFS) claims data, including inpatient (Part A) and outpatient (Part B) services, provide a valuable resource for research on older adults (≥65 year) in linked U.S. cohorts. Here we describe our experience linking the Agricultural Health Study cohort, including 47,501 licensed pesticide applicators and spouses from North Carolina (NC) and Iowa (IA) to Medicare claims data from 1999 to 2016. Given increased Part C (i.e., managed care/Medicare Advantage) enrollment during this period, and a resulting lack of available Part C claims data prior to 2015, we also explored potential for informative missingness. We compared those with partial or limited/no FFS to those with complete FFS coverage (i.e., ≥11 months per year parts AB, but not C, throughout Medicare enrollment) in relation to baseline farm size, general pesticide use, and mortality, in logistic regression models adjusted for age, sex, race, education, and smoking, and stratified by state. While 46,689 participants (98%) were linked to Medicare IDs, only 33,487 (70%) had complete FFS, 9353 (20%) had partial FFS (≥1 year FFS but not complete), and 3849 (8%) had limited/no FFS (Part A or Part C-only). Incomplete FFS was more common in NC, mostly due to Part C, and was associated with farm characteristics, pesticide use, and mortality. These findings indicate that, in addition to reduced sample size in analyses limited to complete FFS, missingness may not be random. The potential impact of incomplete FFS data and changes in coverage type need to be considered when planning linked analyses and interpreting results.

Factors Associated With 7-Day Follow-Up Outpatient Mental Healthcare in Older Adults Hospitalized for Suicidal Ideation, Suicide Attempt, and Self-Harm

OBJECTIVE

Older adults are one of the fastest growing age groups seeking emergency care for suicidal ideation and self-harm. Timely follow-up outpatient mental healthcare is important to suicide prevention, yet little is known about predictors of care continuity following hospital discharge. This study identified patient-, hospital-, and regional-level factors associated with 7-day follow-up outpatient mental healthcare in suicidal older adults.

METHODS

Retrospective cohort analysis using 2015 Medicare data for adults aged ≥65 years hospitalized for suicidal ideation, suicide attempt, or deliberate self-harm (n = 27,257) linked with the American Hospital Association survey and Area Health Resource File. Rates and adjusted risk ratios stratified by patient, hospital, and regional variables were assessed for 7-day follow-up outpatient mental healthcare.

RESULTS

Overall, 30.3% of patients received follow-up mental healthcare within 7 days of discharge. However, follow-up rates were higher for patients with any mental healthcare within 30 days prehospitalization (43.7%) compared to patients with no recent mental healthcare (15.7%). Longer length of stay and care in psychiatric hospitals were associated with higher odds of follow-up. For patients with no mental healthcare in the 30 days prehospitalization, discharge from hospitals that were large, system-affiliated, academic medical centers, or provided hospitalist-based care were associated with lower odds of follow-up. Females were more likely to receive 7-day follow-up, whereas non-white patients were less likely to receive follow-up care.

CONCLUSION

Timely follow-up is influenced by multiple patient, hospital, and community characteristics. Findings highlight the need for quality improvement to promote successful transitions from inpatient to outpatient care.

Trends in Disenrollment and Reenrollment Within US Commercial Health Insurance Plans, 2006-2018

IMPORTANCE

The commercial health insurance market is characterized by consistently high enrollee turnover. Turnover can disrupt care continuity for patients and create challenges for insurers in managing the health of their enrollee populations. Yet the extent to which enrollees reenroll is not widely known.

OBJECTIVE

To characterize rates of disenrollment (hereafter, external turnover) and reenrollment in commercial health plans.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective longitudinal cohort study, trends in turnover and reenrollment in commercial health plans between January 1, 2006, and August 31, 2018, were analyzed. Data analysis was conducted from January 21, 2020, through December 23, 2021. Participants included 3 018 633 primary members and their dependents with employer-sponsored coverage.

MAIN OUTCOMES AND MEASURES

Primary outcomes included external turnover from commercial coverage and subsequent reenrollment into any line of business with the insurer (commercial, Medicaid Managed Care, and Medicare Advantage). Within commercial coverage, external turnover was analyzed separately for group (ie, employer-sponsored) and individual markets.

RESULTS

In the sample of 3 018 633 members, 50.2% were men; mean (SD) age, including dependents, was 30.68 (19.05) years. A total of 2.2% of members experienced external turnover each month and 21.5% experienced external turnover each year. The individual market had the highest average monthly turnover rate of 3.4% compared with 2.1% in the group market. December had the highest rate of external turnover, with 13.8% experiencing external turnover in the individual market and 6.9% of members experiencing external turnover in the group market. Fourteen percent of the members who left the insurer from an individual plan reenrolled with the insurer after 1 year, and 34% had reenrolled after 5 years. Among members who left the insurer from a group plan, 12% reenrolled after 1 year and 32% reenrolled after 5 years. After 10 years, reenrollment reached 47% in the 2 markets. More than 80% of enrollees returned to the same line of business and within the same state, suggesting findings may generalize to smaller insurers.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that insurers may benefit from investing in members' long-term health outcomes despite substantial short-term turnover rates.

Understanding Consumer Experiences and Insurance Outcomes Following Plan Disenrollment in the Nongroup Insurance Market

Disenrollment from health plans purchased on Affordable Care Act (ACA) Marketplaces is frequent; little is known whether disenrollment from off-Marketplace plans is as common or about the experiences and consequences of disenrollment. Using longitudinal administrative data on 2017-2018 nongroup plan enrollment linked with survey data, we analyze plan disenrollment in one regional insurance carrier servicing three states. Overall, 71% of enrollees disenrolled from their 2017 plan. Disenrollment was associated with purchasing through an ACA Marketplace, the carrier making significant changes to an enrollee's plan benefit design, being healthier, being younger, and paying a higher premium for their 2017 plan in 2018. Experiencing financial burden or poor access to preferred providers was not associated with disenrollment. Most disenrollees (93.2%) enrolled in other coverage, often at a lower premium, but lacked confidence that they could afford needed care. These results can inform policy to support enrollees through coverage transitions and foster stability in the nongroup market.

Suicide risk in first year after dementia diagnosis in older adults

INTRODUCTION

Receiving a diagnosis of Alzheimer's disease or related dementias (ADRD) can be a pivotal and stressful period. We examined the risk of suicide in the first year after ADRD diagnosis relative to the general geriatric population.

METHODS

We identified a national cohort of Medicare fee-for-service beneficiaries aged ≥ 65 years with newly diagnosed ADRD (n = 2,667,987) linked to the National Death Index.

RESULTS

The suicide rate for the ADRD cohort was 26.42 per 100,000 person-years. The overall standardized mortality ratio (SMR) for suicide was 1.53 (95% confidence interval [CI] = 1.42, 1.65) with the highest risk among adults aged 65 to 74 years (SMR = 3.40, 95% CI = 2.94, 3.86) and the first 90 days after ADRD diagnosis. Rural residence and recent mental health, substance use, or chronic pain conditions were associated with increased suicide risk.

DISCUSSION

Results highlight the importance of suicide risk screening and support at the time of newly diagnosed dementia, particularly for patients aged < 75 years.

Comparison of Ambulatory Care Access and Quality for Beneficiaries With Disabilities Covered by Medicare Advantage vs Traditional Medicare Insurance

Question

Do Medicare beneficiaries aged 18 to 64 years with disability entitlement have different rates of enrollment in Medicare Advantage (MA) vs traditional Medicare (TM) compared with other beneficiaries, and how do the 2 programs compare on rates of ambulatory care access and quality for beneficiaries with disabilities?

Findings

In this cohort study of a nationally representative sample of 7201 person-years for Medicare beneficiaries in 2015 through 2018, beneficiaries with disability entitlement were significantly less likely to enroll in MA compared with those without disability entitlement. However, enrollment in MA vs TM was associated with better outcomes on 2 of 3 access measures and 3 of 3 quality measures for beneficiaries with disabilities.

Meaning

Although Medicare beneficiaries with disabilities enrolled in MA at lower rates than other beneficiaries in this study, MA appeared to compare favorably with TM in meeting key ambulatory care access and quality measures for beneficiaries with disabilities.

Importance

Medicare beneficiaries with disabilities aged 18 to 64 years face barriers accessing ambulatory care. Past studies comparing Medicare Advantage (MA) with traditional Medicare (TM) have not assessed how well these programs meet the needs of beneficiaries with disabilities.

Objective

To compare differences in enrollment rates, ambulatory care access, and ambulatory care quality for beneficiaries with disabilities in MA vs TM.

Design, Setting, and Participants

This cohort study included a nationally representative, weighted sample of 7201 person-years for beneficiaries aged 18 to 64 years with disability entitlement in the Medicare Current Beneficiary Survey from 2015 through 2018. Differences in program enrollment and in measures of access and quality by program enrollment were compared after adjusting for demographic, insurance, social, health, and area characteristics and after reweighting the sample by propensity to enroll in MA as estimated by observed confounders. Data analyses were conducted between November 1, 2020, and November 11, 2021.

Exposures

Medicare Advantage vs TM program enrollment.

Main Outcomes and Measures

Six patient-reported measures of ambulatory care access (usual source of care, primary care usual source of care, specialist visit) and quality (cholesterol screening, influenza vaccination, colon cancer screening).

Results

The mean (SD) age of the overall study population was 52.1 (11.0) years; 49.5% were female and 50.5% were male; 1.6% were Asian/Pacific Islander; 17.4%, Black; 10.2% Hispanic; 1.4%, Native American; 65.1%, White, and 4.2%, multiracial. Among all beneficiaries living in the community, individuals with disability entitlement were less likely to enroll in MA than other beneficiaries (34.8% vs 41.2%). The final sample of beneficiaries with disabilities included 2444 person-years in MA and 4757 person-years in TM. Beneficiaries with disabilities in MA vs TM were more likely to be of a minority race or ethnicity (35.7% vs 27.6%) and less likely to be enrolled in private insurance (11.9% vs 25.0%). Comparing MA with TM among beneficiaries with disabilities, those in MA had significantly better rates of access to a usual source of care (90.2% vs 84.9%; adjusted propensity-weighted marginal difference [APWMD], 2.9%; 95% CI, 0.2%-5.7%), access to specialist visits (53.2% vs 44.8%; APWMD, 5.5%; 95% CI, 0.6%-10.5%), cholesterol screenings (91.1% vs 86.4%; APWMD, 3.8%; 95% CI, 0.9%-6.7%), influenza vaccinations (61.4% vs 51.5%; APWMD, 10.4%; 95% CI, 5.3%-15.5%), and colon cancer screenings (68.4% vs 54.6%; APWMD, 10.3%; 95% CI, 4.8%-15.8%).

Conclusions and Relevance

In this cohort study, Medicare beneficiaries with disabilities were enrolled in MA at significantly lower rates than those without disabilities. However, MA was associated with significantly better ambulatory care access and quality for these beneficiaries on 5 of 6 measures compared with TM.

The Relationship Between Medicare Advantage Star Ratings and Enrollee Experience

BACKGROUND

Medicare Advantage plans, private managed care plans that enrolled 34% of Medicare beneficiaries in 2019, received $6 billion in annual bonus payments on the basis of their performance on a 5-star rating system. Little is known, however, as to the extent these ratings adequately capture enrollee experience.

OBJECTIVES

To measure the effect of exposure to higher rated Medicare Advantage contracts on enrollee experience.

DESIGN

An instrumental variables analysis using MA contract consolidation as an exogenous shock to the quality of plan enrollees are exposed to.

PARTICIPANTS

A total of 345,897 MA enrollees enrolled in non-consolidated contracts and 21,405 enrollees who were consolidated.

MAIN MEASURES

The primary exposure was enrollee star rating, instrumented using contract consolidation. The primary outcomes were enrollee self-reported experience measures.

KEY RESULTS

There were no significant effects on increased star ratings on 23 of 27 outcomes. A one-star increase in contract star rating leads to a 5.4 percentage point increase in reporting that pain does not interfere with daily activities (95%CI 2.4, 8.4), and a 4.4 percentage reduction in the likelihood that a physician would talk to the enrollee about physical activity (95%CI: -7.8, -1.1, all p<0.05). A one-star increase in contract star rating led to an 8.4 percentage point reduction in achieving the top score on the received needed information index (95%CI: -16.4, -0.4), and a 1.8 percentage point reduction in responding with the lowest score for the overall rating of care (95%CI: -3.5, -0.1).

CONCLUSIONS

Exposure to a higher rated MA contract did not appreciably increase enrollee experience. Policymakers should consider reassessing how these ratings and associated bonus payments are currently calculated.

Racial Disparities in Avoidable Hospitalizations in Traditional Medicare and Medicare Advantage

IMPORTANCE

Compared with traditional Medicare (TM), Medicare Advantage (MA) has the potential to reduce racial disparities in hospitalizations for ambulatory care sensitive conditions (ACSC). As racial disparities may be partly attributable to unequal treatment based on where people live, this suggests the need of examining geographic variations in racial disparities.

OBJECTIVE

The aim of this study was to examine differences in ACSC hospitalizations between White and Black beneficiaries in TM and MA and examine geographic variations in racial differences in ACSC hospitalizations in TM and MA.

METHODS

We analyzed the 2015-2016 Medicare Provider Analysis and Review files. We used propensity score matching to account for differences in characteristics between TM and MA beneficiaries. Then, we conducted linear regression and estimated adjusted outcomes for TM and MA beneficiaries by race. Also, we estimated racial differences in adjusted outcomes by insurance and hospital referral region (HRR).

RESULTS

While White beneficiaries in TM and MA had similar rates of ACSC hospitalizations (163.7 vs. 162.2/10,000 beneficiaries), Black beneficiaries in MA had higher rates of ACSC hospitalizations than Black beneficiaries in TM (221.2 vs. 209.3/10,000 beneficiaries). However, the racial differences were greater in MA than TM (59.0 vs. 45.6/10,000 beneficiaries). Racial differences in ACSC hospitalizations in MA were prevalent across almost all HRRs. 95.5% of HRRs had higher rates of ACSC hospitalizations among Black beneficiaries than White beneficiaries in MA relative to just 54.2% of HRRs in TM.

CONCLUSION

Our findings provide evidence of racial disparities in access to high-quality primary care, especially in MA.

Leveraging survey and claims data to identify high-need Medicare beneficiaries in the National Health and Aging Trends Study

BACKGROUND

Multiple algorithms have been developed to identify and characterize the high-need (HN) Medicare population. However, they vary in components and yield different populations, and were developed for varying purposes. We compared the performance of existing survey and claims-based definitions in identifying HN beneficiaries and predicting poor outcomes among a community-dwelling population.

METHODS

A retrospective cohort study using Round 5 (2015) of the National Health and Aging Trends Study (NHATS) linked with Medicare claims. We applied HN definitions from previous studies to our cohort of community-dwelling, fee-for-service beneficiaries (n = 4201) using sampling weights to obtain nationally representative estimates. The Bélanger et al. (2019) definition defines HN as individuals with complex conditions, multi-morbidity, acute and post-acute healthcare utilization, dependency in activities of daily living, and frailty. The Hayes et al. (2016) definition defines HN as individuals with 3+ chronic conditions and a functional limitation. We applied each definition to survey and claims data. Outcomes were hospitalization or mortality in the subsequent year.

RESULTS

The proportion of NHATS respondents classified as HN varied greatly across definitions, ranging from 3.1% using the claims-based Hayes definition to 32.9% using the survey-based Bélanger definition. HN respondents had significantly higher mortality and hospitalization rates in 2016. Although all definitions had good specificity, none were able to predict outcomes in the following year with good accuracy.

CONCLUSIONS

While mortality and hospitalization rates were significantly higher among respondents classified as HN, existing claims and survey-based HN definitions were not able to accurately predict future outcomes in a community-dwelling, nationally representative sample measured by the area under the curve.

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare

BACKGROUND/OBJECTIVE

Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment.

MEASUREMENTS

Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing.

RESULTS

Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM.

CONCLUSIONS

Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.

Plan switching among Medicare Advantage beneficiaries with Alzheimer's disease and other dementias

INTRODUCTION

Patients with Alzheimer's disease and related dementias (ADRD) face substantial challenges in selecting, and remaining enrolled in, health insurance. Little is known about how patients with ADRD experience the Medicare Advantage (MA) program.

METHODS

We used, hospital, outpatient, and post-acute care data to identify MA beneficiaries with and without ADRD in 2014. Multinomial logit models estimated the percentage of people who disenrolled to traditional Medicare (TM) or switched to a different MA plan in 2015.

RESULTS

Among non-dually eligible beneficiaries, 9.0% (95% confidence interval [CI]: 8.0, 9.1) with ADRD disenrolled while 19.7% (95% CI: 19.6, 19.9) switched plans within MA compared to a disenrollment rate of 4.2% (95% CI: 4.2, 4.2) and switching rate of 22.8% (95% CI: 22.9, 22.8) for persons without ADRD.

DISCUSSION

MA enrollees with ADRD tend to disenroll at substantially higher rates than those without ADRD. This may be indicative of their care needs not being met in the program.

Rural Enrollees In Medicare Advantage Have Substantial Rates Of Switching To Traditional Medicare

Medicare beneficiaries in rural areas may face challenges to gaining access to care, particularly if enrolled in Medicare Advantage (MA) plans with limited benefits and restrictive provider networks. These barriers to care may, in turn, increase switching to traditional fee-for-service Medicare among rural MA enrollees. Using 2010-16 Medicare Current Beneficiary Survey data, we found that switching from traditional Medicare to Medicare Advantage was uncommon among enrollees, both rural (1.7 percent) and nonrural (2.2 percent). Switching from Medicare Advantage to traditional Medicare was more common in both settings, especially for rural enrollees (10.5 percent) compared with nonrural enrollees (5.0 percent). The differential was even greater among rural enrollees who were high cost or high need. Of eleven care satisfaction variables we examined, dissatisfaction with care access had the strongest association with switching from Medicare Advantage to traditional Medicare among rural enrollees. Our findings point to the importance of developing policies targeted at improving care access for rural MA enrollees.

Mandated Copayment Reductions in Medicare Advantage: Effects on Skilled Nursing Care, Hospitalizations, and Plan Exit

OBJECTIVES

To address concerns that postacute cost-sharing may deter high-need beneficiaries from participating in Medicare Advantage (MA) plans, the Centers for Medicare and Medicaid Services have capped cost-sharing for skilled nursing facility (SNF) services in MA plans since 2011. This study examines whether SNF use, inpatient use, and plan disenrollment changed following stricter regulations in 2015 that required most MA plans to eliminate or substantially reduce cost-sharing for SNF care.

DESIGN

Difference-in-differences retrospective analysis from 2013 to 2016.

SETTING

MA plans.

PARTICIPANTS

Thirty-one million MA members in 320 plans with mandatory cost-sharing reductions and 261 plans without such reductions.

MEASUREMENTS

Mean monthly number of SNF admissions, SNF days, hospitalizations, and plan disenrollees per 1000 members.

RESULTS

Mean total cost-sharing for the first 20 days of SNF services decreased from $911 to $104 in affected plans. Relative to concurrent changes in plans without mandated cost-sharing reductions, plans with mandatory cost-sharing reductions experienced no significant differences in the number of SNF days per 1000 members (adjusted between-group difference: 0.4 days per 1000 members [95% confidence interval (95% CI), -5.2 to 6.0, P=0.89], small decreases in the number of hospitalizations per 1000 members [adjusted between-group difference: 0.6 admissions per 1000 members (95% CI, -1.0 to -0.1; P=0.03)], and small decreases in the number of SNF users who disenrolled at year-end [adjusted between-group difference: -16.8 disenrollees per 1000 members (95% CI, -31.9 to -1.8; P=0.03)].

CONCLUSIONS

Mandated reductions in SNF cost-sharing may have curbed selective disenrollment from MA plans without significantly increasing use of SNF services.

Seniors don't use Medicare.Gov: how do eligible beneficiaries obtain information about Medicare Advantage Plans in the United States?

BACKGROUND

Managed care programs in the US are becoming a preferred alternative among low-income individuals in the US. Every year during open enrollment, seniors can enroll in Medicare Advantage (MA) or switch MA plans. However, there is very limited information about how seniors obtain information to help them make their choices. While the Centers for Medicaid and Medicare offer online resources that are designed to enable potential beneficiaries to make informed coverage decisions, there is no information as to whether seniors use these resources, and therefore whether these resources are effective compared to other information retrieval methods.

METHODS

The purpose of the present study was to qualitatively explore how seniors obtain information about insurance plans in MA. We conducted semi-structured interviews with 26 MA beneficiaries from Rhode Island.

RESULTS

We found that most seniors have strong preferences for obtaining information in-person regarding benefits, cost and other plan information. Some seniors relied heavily on insurance brokers or representatives, and considered the information provided to them without questioning the potential for bias. Others consulted with family and/or friends for guidance, or to compare costs and benefits. Only a few of these seniors used the available internet resources, and in fact most of them mentioned that they did not have a computer/smart device with internet capabilities. However, among those who used and appeared to be comfortable with navigating the internet, www.medicare.gov was not discussed as a useful resource for making decisions regarding health insurance.

CONCLUSIONS

This study suggests that existing online medical resource usage and effects among senior citizens in the United States may need supplementing with in-person communication among influential agents.

Higher Medicare Advantage Star Ratings Are Associated With Improvements In Patient Outcomes

Little is known about how well the Centers for Medicare and Medicaid Services' five-star rating system for the overall quality of Medicare Advantage (MA) contracts captures quality of care. Leveraging contract consolidation as a natural experiment to study the association between outcomes and insurer-initiated enrollee shifts to plans with higher-rated contracts, we found that enrollees experiencing a one-star MA rating increase were 20.8 percent less likely to voluntarily leave their plan to enroll in another plan or traditional Medicare. When hospitalized, they were 3.4 percent more likely to use a higher-quality hospital and 2.6 percent less likely to be readmitted within ninety days. Our findings suggest that MA star ratings may capture key domains of an MA plan's quality; however, the differences in outcomes that they capture might not all be clinically meaningful.

Factors Associated With Home-Hospice Utilization

Utilization of hospice for end-of-life care is known to be lower among racial and ethnic minority groups than among White populations when controlling for other socioeconomic factors. Certain patient, provider, and community characteristics may influence home-hospice use. We sought to identify patient, provider, and community factors associated with home-hospice use. Our final analytic sample included 1,208,700 hospice patients who received home-hospice from 2,148 Medicare-certified hospice providers in 2016. We found that an increase in the proportion of hospice patients with a primary diagnosis of dementia decreased the odds that home-hospice was provided (OR = 1.42, 95% CI = 1.36-1.48). Patients who received hospice care from a provider with a higher proportion of dually enrolled patients were less likely to receive home-hospice (OR = 1.42, 95% CI = 1.36-1.48) and hospices located in ZIP-codes with higher proportion of Hispanic resident were less likely to provide home-hospice (OR = 1.00, 95% CI = 0.99-0.99). Additional research is needed to clarify the mechanisms underlying these associations.

Differences in Health Care Utilization, Process of Diabetes Care, Care Satisfaction, and Health Status in Patients With Diabetes in Medicare Advantage Versus Traditional Medicare

OBJECTIVE

The objective of this study was to determine differences in health care utilization, process of diabetes care, care satisfaction, and health status for Medicare Advantage (MA) and traditional Medicare (TM) beneficiaries with and without diabetes.

METHODS

Using the 2010-2016 Medicare Current Beneficiary Survey, we identified MA and TM beneficiaries with and without diabetes. To address the endogenous plan choice between MA and TM, we used an instrumental variable approach. Using marginal effects, we estimated differences in the outcomes between MA and TM beneficiaries with and without diabetes.

RESULTS

Our instrumental variable analysis showed that compared with TM beneficiaries with diabetes, MA beneficiaries with diabetes had less annual health care utilization, including -22.4 medical provider visits [95% confidence interval (CI): -23.6 to -21.1] and -3.4 outpatient hospital visits (95% CI: -3.8 to -3.0). A significant difference between MA and TM beneficiaries without diabetes was only observed in medical provider visits and the difference was greater among beneficiaries with diabetes than beneficiaries without diabetes (-12.5 medical provider visits; 95% CI: -15.9 to -9.2). While we did not detect significant differences in 5 measures of the process of diabetes care between MA and TM beneficiaries with diabetes, there were inconsistent results in the other 3 measures. There were no or marginal differences in care satisfaction and health status between MA and TM beneficiaries with and without diabetes.

CONCLUSIONS

MA enrollment was associated with lower health care utilization without compromising care satisfaction and health status, particularly for beneficiaries with diabetes. MA may have a more efficient care delivery system for beneficiaries with diabetes.